Basic Information
| Provider Information | |||||||||
| NPI: | 1104985696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025602900 | ||||||||
| FaxNumber: | 7025602990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 SIENA HEIGHTS DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026171227 | ||||||||
| FaxNumber: | 7024929574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1201 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1104985696 | 05 | NV | MEDICAID | P01254908 | 01 | NV | RAILROAD MEDICARE | OTHER |